THE LATEST clinical guidelines from the American College of Gastroenterology (ACG) aim to improve the diagnosis and treatment of eosinophilic oesophagitis (EoE), reflecting paradigm shifts and increases in knowledge from the past decade.
EoE is a chronic immune-mediated disorder of the oesophagus, characterised by oesophageal dysfunction symptoms and eosinophilic infiltration in the oesophagus. The condition is increasingly common in gastroenterology, allergy practices, emergency departments, and primary care settings.
EoE is diagnosed by identifying symptoms such as difficulty swallowing and heartburn, combined with at least 15 eosinophils per high-power field in an oesophageal biopsy. The updated guidelines recommend using a systematic endoscopic scoring system, such as the EoE Endoscopic Reference Score (EREFS), to characterise endoscopic findings at each endoscopy. Additionally, at least six biopsies from two different oesophageal levels should be obtained to assess histologic features consistent with EoE. The guidelines stress the importance of quantifying eosinophil counts from every biopsy to guide diagnosis and treatment.
For treatment, proton pump inhibitors (PPI) are suggested as a potential therapy for EoE. The use of swallowed topical steroids, such as fluticasone propionate or budesonide, is strongly recommended as the primary treatment for EoE. The guidelines also suggest an empiric food elimination diet for patients with EoE, although the use of allergy testing to direct these diets is not recommended due to the low quality of evidence supporting its effectiveness.
For patients who do not respond to PPI therapy, the biologic drug dupilumab is recommended for individuals aged 12 years and older, as well as for paediatric patients aged 1–11 years who are unresponsive to PPIs. Endoscopic dilation is also advised as an adjunct to medical therapy for those with oesophageal strictures that cause dysphagia.
Furthermore, the guidelines recommend ongoing monitoring of treatment response through clinical, endoscopic, and histologic assessments. For children with EoE and dysphagia, an oesophagram should be considered to evaluate fibrostenotic disease. For paediatric patients with feeding dysfunction, evaluation by a feeding therapist or dietician is suggested as an adjunctive intervention.
To prevent symptom recurrence, histologic inflammation, and endoscopic abnormalities, the guidelines emphasise the importance of continuing effective dietary or pharmacologic therapy. Regular evaluation of treatment response, including both symptomatic and endoscopic outcomes, is crucial to ensuring successful long-term management of EoE.
With these recommendations, the guidelines aim to provide a comprehensive framework for clinicians to better manage the increasing prevalence of EoE and improve patient outcomes.
Ada Enesco, EMJ
Reference
Dellon ES et al. ACG clinical guideline: diagnosis and management of eosinophilic esophagitis. Am J Gastroenterol. 2025;120(1):31-59.
